Mentoring Application

Applicant Information

PARENTS/GUARDIANS: Please see the bottom of this form for information on the mentoring contract that must be signed.

Power is the Talents, Abilities, Skills, Knowledge and Strategies you use as leverage to control your destiny. Control over the choices of your life helps you achieve your most powerful purpose. The reason for this form is to give us information to see how we might help you along your Passage to achieving this POWER. Please be as complete, honest and thorough as you possibly can. The more we know about you, the better chance we have to match you with the right mentor.

Your Name (First, Middle Initial, Last, Suffix)

Address

City/State/Zip

Home Phone

Cell Phone

Email

Date of Birth

Gender MaleFemale

Parent/Guardian Information

Parent/Guardian Name (First and Last)

Cell Phone

Email

Parent/Guardian Name (First and Last)

Cell Phone

Email

Emergency Contact (if other than parents/guardians)

Name (First, Middle Initial, Last, Suffix)

Relationship

Phone

Email

Schooling Information

Name of School Attending

Grade

List of Current Classes

Favorite Subjects

Subjects You're Unsure About

Your Interests

What are your hobbies and interests? How can these help you gain your true power?

What extracurricular activities outside of school do you participate in (e.g. Scouts, youth programs)? Explain how you think these might help you gain your full power.

What is your vision for yourself when you are grown?

What do you know about how college can help you achieve your power?

How do you think a mentor can help you on your passage to power?

How do you think you can help your mentor on his passage to power? What strengths do you bring to the relationship?

What is your favorite food?

What is your favorite color?

What is your favorite person?

What is your favorite book?

What is your favorite movie?

What is your favorite song?

What is your favorite musical group?

Match Information

What days of the week are you available to participate? (Check all that apply)MondayTuesdayWednesdayThursdayFridaySaturdaySunday

What is the best time of day for you to participate? (Check all that apply)MorningsAfternoonsEveningsWeekends

What three words best describe you?

Medical

Do you have any of the following medical conditions that the program should be aware of?

Allergies (food or otherwise)YesNo

If yes, please specify

Behavioral issuesYesNo

If yes, please specify

Concentration and/or focus issuesYesNo

If yes, please specify

Other conditionsYesNo

If yes, please specify

Essay

Please prepare a short essay (1 full page, single-spaced, in your own handwriting [not typed please]) explaining what you know about 100 Black Men, what you expect out of the mentoring program and your current feelings and anticipations about participating in the program. Please make this a separate sheet and attach to this application.

Parents please do not assist in this essay, no matter the student’s age. We want to know the level of performance on this task of your protégé and will use it to determine what level of assistance we might be able to provide.

Submitting this form does not guarantee that you will be provided with a mentor from the 100 Black Men of Maryland. It merely gives us a point of departure to see if we possess the resources to help you meet your goals.

Contact Information

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One Hundred Black Men of Maryland is a 501c3 nonprofit, tax deductible, corporation dedicated to the uplift of the African American community through national umbrella services known as “Mentoring the 100 Way Across a Lifetime.” We are an autonomous chapter of an international network of men striving to elevate the opportunities for our people through radical improvements in health, education and wealth.